Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr. Warrick Bishop and I'd like to welcome you to my podcast station and of course to the Healthy Heart Network. Today, I'm delighted to say I have a guest, a specialist cardiologist from Adelaide with an interest in rehabilitation, Dr. Alistair Begg. Thank you for joining us today, Alistair. Thank you for having me on your show, Warrick. Look, for those who have had the chance, you may have heard the first interview that I had with Dr. Begg talking about cardiac rehabilitation and what it really means. Well, in very simple terms, Alistair, do you want to just remind us what the overarching concepts are for cardiac rehabilitation? And then we're going to drill down in a little bit more detail so we can find some relevance. for particular individuals and the questions they may have of their own care. So over to you, Alistair. Well, look, the cardiac rehabilitation process is really about the journey that patients have after a cardiac event. So someone that's had a heart attack or heart surgery or stent, they're often a bit shell-shocked. And really the cardiac rehabilitation journey picks up the pieces after that event. looks at why the patient's there in the first place, how has it happened, and what they need to do about it to try and prevent a future event. Essentially, that's the sort of overall game plan, if you like, for cardiac rehabilitation. And we can sort of discuss what that looks like, but that's really the overarching concept. So to a large degree... And I imagine this is the process, Alistair, when a patient has a cardiac event, we first of all start off by taking an inventory of exactly what risks, what factors may have brought them to that condition. Would that be a fair thing to say? You can't be worried. Well, look, most people, when something happens, particularly when it's out of the blue, the first question they ask is, why me? And cardiac rehabilitation and education about the risk factors often gives a very good clue to the patient as to why they've developed their particular condition in the first place. And not only is that helpful for the patient as it gives them answers, it's also very helpful for the medical team looking after the patient because if you can track down why something's happened in the first place, you're much more likely to prevent it happening again. So you'll be able to correct me on this, Alistair, but on the top of my mind as I'm looking at someone's, if you like, cardiac risk health inventory, I'm sort of thinking about smoking and I don't want them smoking. I'm thinking about them maybe being diabetic. I'm thinking about their blood pressure. I'm thinking about their cholesterol levels. I'm thinking about their family history. Are these the sort of things that you have front of mind when you're evaluating a patient that first time? Certainly, Warrick. Well, look, certainly one of the first things I ask patients, even before we've really had much of a discussion, is do they have a family history of early onset of heart disease? By early onset, I mean perhaps under 65 years. and particularly under 55 years, the increased risk for that patient is certainly profound. If there's one parent that's in that group, maybe double your risk for heart disease. If there's two parents affected, it might increase by four times. So certainly from a cardiologist's point of view, it gives us a very clear risk assessment if we ask that one question of a patient. That's not the only factor, but that's one of the main, if you call non-modifiable risk factors. So that's something that we really can't do much about, so our parents. When we talk about other risk factors, they usually come into the category of acquired risk factors. That means risk factors that you weren't necessarily born with. So what I might do is just jump in there briefly, Alistair, if that's okay. I'll just share with you my own assessment of family history and its significance because, like you, I'm sure you have patients come in who say, sure, I've got coronary disease in the family. My great uncle Bulgaria had a heart attack at 93 years of age. When, of course, we're talking to a 45-year-old male, you sort of realise that patients... need to recognize exactly what you said, that where we recognize that many people, in fact, 50% of the population will die from coronary artery disease given long enough. But our concern is about families where these events happen early on. And what I say to my patients is we're interested in first degree relatives. That's mothers or fathers, brothers or sisters. When the male is less than 55. and the woman is less than 60 years of age without any other significant issue like a smoking history or marked obesity, which may be contributory to that. Is that the sort of guideline that you tend to sort of share with your patients, Alistair? Yeah, I think it's important to put these family history factors into perspective. And as you say, certainly if the great-grandfather... had a heart attack at 95 well that that's probably really not significant in terms of your own personal risk for heart disease but certainly if there's a strong family history if all the brothers have had stents and they're only a couple of years older than the person sitting in front of you who's 48 years of age then that should ring some alarm bells both for the cardiologist and also for the patient so that's a sort of high risk patient that We really want to be aggressive about investigating and managing their risk factors to try and prevent what's likely to be a fairly inevitable event if there's a strong family history if we don't do anything about it. Alistair, I really like the way you make the distinction between modifiable and non-modifiable risks because you can't pick your family. You're just stuck with them. Whatever genes they give you, you've got them for life. But one of the most significant modifiable risks is smoking. How do you approach that conversation with patients if they've had a cardiac event? Smoking has been contributory leading up to that. What sort of conversation do you have with those individuals? Well, look, first and foremost, it's obviously an education process. So it's important to educate the patient about the risks of smoking. And there's certainly evidence that if the doctor tells people to stop smoking, it can have a profound effect in terms of modifying that risk factor. Having said that, that's not the only way that we can prevent people smoking in the future. We can enrol people in certain programs, such as the QuickLine, which is a program that's available, and those programs can send people reminders to... It's about quitting smoking. The general practitioners are a very important part of that process in terms of seeing the patient regularly and coaching the patient and potentially using certain nicotine replacement tools which have been shown to be effective in trying to reduce the lifelong risk of smoking. It's certainly a very expensive habit as well in educating people about the savings that have been... achieved with stopping smoking is also important as well. From my own experience in that space, I really try and engage those patients and find out right off the bat, are they prepared to change or not? Do they recognise that smoking has contributed to where they are and are they genuinely open to change? To be honest, I do that because if they say, look, no, I don't want to change, doc, then I don't actually push hard with the conversation because otherwise they push back and I can lose a patient who I may be able to help with other modifier risks. modifiable risk factors, hoping that they eventually come back round. As long as we don't lose that relationship, we may be able to work on smoking at a later time. So one of my early conversations with these individuals is to really ascertain whether they truly want to be smokers lifelong, if that's who they think they are, or whether they recognise it as a... as a habit that they wish they could kick. And if it's that latter group, then I really jump on all the things you were talking about there to try and support them as best as possible. But I often think that our relationship with the patient is a really, really important starting point in that conversation. So I'm going to roll on to the next tricky one, and I'm going to put you on the spot here. Dr Begg, because I haven't really given you the chance to prep for this, but what about the difficulty of people who are overweight? How do you approach that? Well, I mean, Warrick, as you know, about two-thirds of the adult community is either overweight or obese, and I don't need to tell you, but I think it's important that we say that it is a very... prevalent problem in society, and increasingly so, and that is leading to more and more cases of diabetes and high blood pressure and a whole lot of other health risks apart from heart disease. So having said that, I mean, my approach is multifaceted. Once again, you have to understand the patient and what the key drivers in their weight issues are. I mean, for some people, they have an eating problem and they need lots of education about that. For some people, it might be that they just don't exercise. Although I think for the majority of people, it's more of an issue with what they eat rather than how much exercise they do. But it's important to ascertain how much exercise they're doing, what type of exercise, how often they're exercising. So you can look at the whole picture. You might ask what they've tried in the past to try and lose weight. What works for them? I don't think there's one solution for everybody with weight loss. A lot of people respond to these programs where people can buy healthy meals for a month, maybe to get them started. In the more recalcitrant cases, we sometimes discuss interventional approaches to obesity where... The simple methods haven't worked. Areas such as gastric surgery or possibly medication that's available now to help the patient with weight loss. And I often engage the GP in those discussions as well. So that's my overall approach to managing weight. But I think it is very important that you educate the patient about what the... effects of weight loss in terms of benefits, perhaps in terms of reducing blood pressure and cholesterol and less sort of general health risks such as arthritis in the longer term. You mentioned exercise as part of that weight management strategy and I think that's an incredibly important issue. We know, for example, that some regular exercise is as effective as an antidepressant medication for mood. So that's a very positive effect for individuals. And we know that low mood or depression is linked to coronary disease. So getting out there and doing some exercises, obviously incredibly valuable just for the mind and the soul. But in terms of how much exercise, do you ever guide patients to that? And in fact, my understanding is that there are some guideline recommendations out there. I think the Americans have put out some guidelines on exercise. Are you someone who recommends guideline objectives, targets for exercise, or how do you approach that conversation about exercise, Alistair? I mean, the general advice that cardiologists give as per the Heart Foundation is to exercise for 30 minutes a day for minimum five days a week, and that really should apply to... to everybody. It doesn't have to be done all at once. But the most important thing is to exercise regularly, to exercise to a level that you're comfortable with, because certainly there's evidence that the right sort of level of exercise is where you reach a point where you are sort of moderately breathless. So doing exercise that is either too intense or not intense enough. may actually have either the wrong effects or not enough effects in terms of health benefits. There are more detailed exercise programs for those people that perhaps have diabetes. They might be enrolled with an exercise physiologist to try and manage their exercise in a more structured way. And for some people, I do enlist the benefits of a... dedicated health professional and exercise to often by the GP to try and modify those weight effects in the longer term. It is a real challenge and one that we are constantly confronting and one that we're trying to help navigate patients through. Look, I know we could talk. for hours more on some of these issues, but I'm going to have to pull time on it, Alistair, because we've covered nearly 15 minutes in no time at all. It's been an absolute delight. I thank you for putting this time aside so that we could chat. Say goodbye to everyone on the podcast station. Thanks Warrick for having me and I look forward to catching up at a later stage. Look, I look forward to catching up too because there's a whole heap of other questions that I'd like to get through and that includes things like blood pressure and diabetes management. I'm really interested in stress and I'm also of course really interested in cholesterol. Plus we've got things like... You know, how does a cardiac rehab team get put together? What sort of stuff should you put in your shopping basket? Do you have to take your tablets forever? We've got such a lot to cover on this fascinating topic. I can't wait to get back and share with you again. Alistair, thank you so much for your time. To those listening, I hope we've given you some information which you've found. informative useful if you have any queries or questions drop us a line at members at drWarrickbishop.com if you've got any suggestions for future podcasts please let us know as always i wish you the very best health and please don't die from a heart attack goodbye You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
